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11: Respiratory Emergencies
Cognitive Objectives
(1 of 3)
4-2.1 List the structure and functions of the respiratory
system.
4-2.2 State the signs and symptoms of a patient with
difficulty breathing.
4-2.3 Describe the emergency medical care of the
patient with breathing difficulty.
4-2.4 Recognize the need for medical direction to assist
in the emergency medical care of the patient with
breathing difficulty.
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Cognitive Objectives (2 of 3)
4-2.5 Describe the care of a patient with breathing
distress.
4-2.6 Establish the relationship between airway
management and breathing difficulty.
4-2.7 List signs of adequate air exchange.
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Cognitive Objectives
(3 of 3)
4-2.8 State the generic name, forms, dose,
administration, actions, indications, and
contraindications for the prescribed inhaler.
4-2.9 Distinguish between the emergency medical care
of the infant, child, and adult patient with breathing
difficulty.
4-2.10 Differentiate between upper airway obstruction
and lower airway disease in the infant and child
patient.
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Affective Objectives
4-2.11 Defend EMT-B treatment regimens for various
respiratory emergencies.
4-2.12 Explain the rationale for administering an
inhaler.
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Psychomotor Objectives
4-2.13 Demonstrate the emergency medical care for
breathing difficulty.
4-2.14 Perform the steps in facilitating the use of an
inhaler.
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Respiratory System
7
Anatomy
and Function
of the Lung
8
Characteristics of
Adequate Breathing
• Normal rate and depth
• Regular breathing pattern
• Good breath sounds on both
sides of the chest
• Equal rise and fall of chest
• Pink, warm, dry skin
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Characteristics of
Inadequate Breathing
• Pulmonary vessels become
obstructed.
• Alveoli are damaged.
• Air passages are obstructed.
• Blood flow to the lungs is
obstructed.
• Pleural space is filled.
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Signs of
Inadequate Breathing
• Slower than 12
breaths/min or faster than
20 breaths/min
• Unequal chest expansion
• Decreased breath sounds
• Muscle retractions
• Pale or cyanotic skin
• Cool, damp (clammy)
skin
• Shallow or irregular
respirations
• Pursed lips
• Nasal flaring
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Dyspnea
• Shortness of breath or difficulty breathing
• Patient may not be alert enough to complain
of shortness of breath.
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Upper or Lower Airway Infection
• Infectious diseases may affect all parts of the
airway.
• The problem is some form of obstruction to the air
flow or the exchange of gases.
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Acute Pulmonary Edema
• Fluid build-up in the lungs
• Signs and symptoms
– Dyspnea
– Frothy pink sputum
• History of chronic congestive heart
failure
• Recurrence high
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Chronic Obstructive Pulmonary
Disease (COPD)
• COPD is the result of direct lung and airway
damage from repeated infections or inhalation
of toxic agents.
• Bronchitis and emphysema are two common
types of COPD.
• Abnormal breath sounds may be present.
– Rhonchi and wheezes
15
Asthma
• Common but serious disease
• Asthma is an acute spasm of the bronchioles.
• Wheezing may be audible without a
stethoscope.
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Spontaneous Pneumothorax
• Accumulation of air in the
pleural space
• Caused by trauma or
some medical conditions
• Dyspnea and sharp chest
pain on one side
• Absent or decreased
breath sounds on one
side
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Anaphylactic Reactions
• An allergen can trigger an asthma attack.
• Asthma and anaphylactic (allergic) reactions can
be similar.
• Hay fever is a seasonal response to allergens.
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Pleural Effusion
• Collection of fluid outside
lung
• Causes dyspnea
• Caused by irritation,
infection, or cancer
• Decreased breath sounds
over region of the chest
where fluid has moved the
lung away from the chest
wall
• Eased if patient is sitting up
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Mechanical Obstruction
of the Airway
• Be prepared to treat quickly.
• Obstruction may result from the position of head, the
tongue, aspiration of vomitus, or a foreign body.
• Opening the airway with the head tilt-chin lift
maneuver may solve the problem.
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Pulmonary Embolism
• A blood clot that breaks off and
circulates through the venous
system
• Signs and symptoms
– Dyspnea
– Acute pleuritic pain
– Hemoptysis
– Cyanosis
– Tachypnea
– Varying degrees of hypoxia
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Hyperventilation
• Overbreathing resulting in a decrease in the
level of carbon dioxide
• Signs and symptoms
– Anxiety
– Numbness
– A sense of dyspnea despite rapid breathing
– Dizziness
– Tingling in hands and feet
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You
thepartner
Provider
• You and
yourare
EMT-B
are dispatched to
1465 Dalles Military Rd for a 33-year-old woman
with difficulty breathing.
• You arrive at the office building and an upset man
identifies himself as the patient’s coworker.
• He tells you that the patient has had breathing
problems before, but he’s never seen it this bad.
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You are the Provider (continued)
• He leads you to a woman who is standing with her
arms outstretched on the desk with a metered-dose
inhaler in hand.
• She acknowledges your presence with a nod.
When you ask her what is wrong, she answers with
a two-word response, “can’t breathe.”
• You hear audible wheezes.
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Scene Size-UP
• How significant is the person’s response to your
question and why?
• What should you do next? Should you transport
this patient or wait for ALS to arrive on scene?
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Initial Assessment
• Perform initial assessment.
• Place the patient on oxygen.
• If patient is in respiratory distress, ventilate.
• Check pulse.
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Signs and Symptoms (1 of 2)
•
•
•
•
•
•
•
Difficulty breathing
Altered mental status
Anxiety or restlessness
Increased or decreased respirations
Increased heart rate
Irregular breathing
Cyanosis
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Signs and Symptoms (2 of 2)
•
•
•
•
•
•
•
Pale conjunctivae
Abnormal breath sounds
Difficulty speaking
Use of accessory muscles
Coughing
Tripod position
Barrel chest
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• You
to rendezvous
with(continued)
ALS.
Youarrange
are the
Provider
• You apply high-flow oxygen and obtain the
following vital signs:
– Respirations: 42 breaths/min
– Pulse oximetry: 90%
• The patient indicates that she has used the inhaler
twice already.
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Youcan
are
Provider
(continued)
• What
youthe
do before
you meet
ALS?
• Another pulse oximetry reading reveals a reading
of 72%.
• The patient is using accessory muscles to breathe.
• What do these signs indicate?
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COPD Patients
• COPD patients cannot handle pulmonary
infections well
• Usually age 50 or older
• History of recurring lung problems
• Long-term smokers
• Tightness in chest/constant fatigue
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Focused History and Physical Exam
• Abnormal breath sounds are symptomatic
of COPD
• Long history of dyspnea with sudden
increase in shortness of breath
• Recent chest cold with fever
• Vital signs
– Normal blood pressure
– Rapid, occasionally irregular pulse
– Respirations rapid or very slow
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Interventions
• Treat immediate life threats
• Possible interventions
– Oxygen via nonrebreathing mask at 15 L/min
– Positive pressure ventilations
– Airway adjuncts
– Positioning
– Respiratory medications
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Detailed Physical Exam
• Performed only once life threats are
addressed.
• May not be able to do if busy treating
airway or breathing problems.
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Ongoing Assessment
• Carefully watch patients for shortness of
breath.
• Reassess vital signs.
• Ask patient if treatment has made a
difference.
• Check for accessory muscle use.
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Emergency Medical Care
• Give supplemental oxygen at 10 to 15
L/min via nonrebreathing mask.
• Patients with longstanding COPD may be
started on low-flow oxygen (2 L/min).
• Assist with inhaler if available.
• Consult medical control.
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Medications in MDI
• Trade names
– Proventil
– Ventolin
– Alupent
– Metaprel
– Brethine
• Generic names
– Albuterol
– Metaproterenol
– Terbutaline
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Prescribed Inhalers
• Actions
– Relax the muscles surrounding the
bronchioles
– Enlarge the airways leading to
easier passage of air
• Side effects
– Increased pulse rate
– Nervousness
– Muscle tremors
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Prior to Administration
• Read label carefully.
• Verify it has been prescribed by a physician for this
patient.
• Consult medical control.
• Make sure the medication is indicated.
• Check for contraindications.
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Contraindications for MDI
• Patient unable to help coordinate inhalation
• Inhaler not prescribed for patient
• No permission from medical control
• Maximum dose prescribed has been taken.
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Administration of MDI (1 of 3)
•
•
•
•
•
Obtain order from medical control or local protocol.
Check for right medication, right patient, right route.
Make sure the patient is alert.
Check the expiration date.
Check how many doses have been taken.
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Administration of MDI (2 of 3)
•
•
•
•
Make sure inhaler is at room temperature or warmer.
Shake inhaler.
Stop administration of oxygen.
Ask the patient to exhale deeply and put lips around
opening.
• If the inhaler has a spacer, use it.
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Administration of MDI (3 of 3)
• Have the patient depress the
inhaler and inhale deeply.
• Instruct the patient to hold his
or her breath.
• Continue administration of
oxygen.
• Allow the patient to breathe a
few times then repeat dose
according to protocol.
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Reassessment
• Carefully watch for shortness of breath.
• 5 minutes after administration:
– Obtain vital signs again.
– Perform focused reassessment.
• Transport and continue to assess breathing.
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Upper or Lower Airway Infection
• Administer warm, humidified oxygen.
• Do not attempt to suction the airway or insert an
oropharyngeal airway in a patient with
suspected epiglottitis.
• Transport patient in position of comfort.
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Acute Pulmonary Edema
• Administer 100% oxygen.
• Suction secretions.
• Transport in position of comfort.
46
Chronic Obstructive Pulmonary
Disease (COPD)
• Assist with prescribed inhaler if patient
has one.
• Transport promptly in position of comfort.
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Spontaneous Pneumothorax
• Administer oxygen.
• Transport in position of comfort.
• Monitor closely.
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Asthma
• Obtain history.
• Assess vital signs.
• Assist with inhaler if patient has one.
• Administer oxygen.
• Transport promptly.
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Pleural Effusion
• Definitive treatment is performed in a
hospital.
• Administer oxygen and support
measures.
• Transport promptly.
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Obstruction of the Airway
• Clear airway.
• Administer oxygen.
• Transport promptly.
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Pulmonary Embolism
• Administer oxygen.
• Place patient in comfortable position,
usually sitting.
• Assist breathing as necessary.
• Keep airway clear.
• Transport promptly.
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Hyperventilation
• Complete initial assessment and history
of the event.
• Assume underlying problems.
• Do not have patient breathe into a paper
bag.
• Give oxygen.
• Reassure patient and transport.
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Review
1. Which of the following patients is breathing
adequately?
A. 36-year-old man with cyanosis around the lips and
irregular respirations
B. 29-year old woman with respirations of 20
breaths/min, who is conscious and alert
C. 22-year-old man with labored respirations at a rate
of 28 breaths/min and pale skin
D. 59-year-old woman with difficulty breathing, whose
respirations are rapid and shallow
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Review
Answer: B
Rationale: Adequate breathing in the adult is
characterized by a respiratory rate between 12 and
20 breaths/min; good chest rise (indicates
adequate tidal volume); unlabored breathing effort;
non-altered mental status; and good perfusion to
the skin (eg, pink, warm, dry).
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Review
1. Which of the following patients is breathing adequately?
A. 36-year-old man with cyanosis around the lips and irregular
respirations
Rationale: A patient with irregular respirations is not breathing
adequately. Cyanosis is a sign of hypoxia.
B. 29-year old woman with respirations of 20 breaths/min, who is
conscious and alert
Rationale: Correct answer
C. 22-year-old man with labored respirations at a rate of 28 breaths/min
and pale skin
Rationale: The normal adult rate of respirations is 12- 20 breaths/min.
D. 59-year-old woman with difficulty breathing, whose respirations are
rapid and shallow
Rationale: A patient with adequate breathing has a normal rate and an
unlabored breathing effort.
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Review
2. The process in which oxygen and carbon dioxide
are exchanged in the lungs is called:
A. respiration.
B. ventilation.
C. metabolism.
D. inhalation.
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Review
Answer: A
Rationale: Respiration is defined as the exchange of
gases between the body and its environment. The
exchange of oxygen and carbon dioxide in the
lungs is called pulmonary (external) respiration.
The exchange of oxygen and carbon dioxide at the
cellular level is called cellular (internal) respiration.
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Review
2. The process in which oxygen and carbon dioxide are
exchanged in the lungs is called:
A. respiration.
Rationale: Correct answer
B. ventilation.
Rationale: Ventilation is the exchange of air between the lungs
and the environment.
C. metabolism.
Rationale: Metabolism is the series of processes by which food is
converted into the energy and products needed to sustain life.
D. inhalation.
Rationale: Inhalation is the active, muscular part of breathing.
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Review
3. Which of the following respiratory diseases causes
obstruction of the lower airway?
A. Croup
B. Asthma
C. Epiglottitis
D. Laryngitis
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Review
Answer: B
Rationale: Asthma is a lower airway disease that
causes the bronchioles in the lungs to constrict
(bronchospasm), resulting in various degrees of
obstruction. Croup, epiglottitis, and laryngitis cause
swelling, inflammation, and varying degrees of
obstruction of the upper airway.
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Review
3. Which of the following respiratory diseases causes
obstruction of the lower airway?
A. Croup
Rationale: This causes an upper airway obstruction.
B. Asthma
Rationale: Correct answer
C. Epiglottitis
Rationale: This causes an upper airway obstruction.
D. Laryngitis
Rationale: This causes an upper airway obstruction.
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Review
4. Albuterol, a beta2 agonist, is the generic name for:
A. Alupent.
B. Metaprel.
C. Brethine.
D. Ventolin.
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Review
Answer: D
Rationale: Albuterol is the generic name for Ventolin
(Proventil). Albuterol is a beta-agonist, which
dilates the bronchioles, and is commonly used to
treat patients with asthma and other reactive
airway diseases.
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Review
4. Albuterol, a beta2 agonist, is the generic name for:
A. Alupent.
Rationale: This is the trade name for Metaproterenol, also a
beta2 agonist.
B. Metaprel.
Rationale: This is the trade name for Metaproterenol, also a
beta2 agonist.
C. Brethine.
Rationale: This is the trade name for Terbutaline, also a beta2
agonist.
D. Ventolin.
Rationale: Correct answer
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Review
5. A 70-year-old man recently had a heart attack and
now complains of severe difficulty breathing,
especially when lying flat. He is coughing up pink,
frothy secretions. This patient is MOST likely
experiencing:
A. acute right heart failure.
B. severe left heart failure.
C. an acute onset of bronchitis.
D. an acute pulmonary embolism.
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Review
Answer: B
Rationale: As a result of his recent heart attack, the
left side of this patient's heart has been severely
damaged. The left side of the heart is responsible
for pumping oxygenated blood to the rest of the
body. When it fails to do this, blood backs up into
the lungs, resulting in pulmonary edema. Signs of
pulmonary edema include dyspnea (especially
when lying flat), rapid and shallow respirations, and
in severe cases, coughing up of pink, frothy
sputum.
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Review (1 of 2)
5. A 70-year-old man recently had a heart attack and now
complains of severe difficulty breathing, especially when
lying flat. He is coughing up pink, frothy secretions. This
patient is MOST likely experiencing:
A. acute right heart failure.
Rationale: Acute heart failure causes a backup of blood into the
systemic circulatory system and typically causes symptoms
of peripheral edema in the hands and feet.
B. severe left heart failure.
Rationale: Correct answer
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Review (2 of 2)
5. A 70-year-old man recently had a heart attack and now
complains of severe difficulty breathing, especially when
lying flat. He is coughing up pink, frothy secretions. This
patient is MOST likely experiencing:
C. an acute onset of bronchitis.
Rationale: This is an acute inflammation of the lungs associated
with a cough, increased sputum, fever, and tachypnea.
D. an acute pulmonary embolism.
Rationale: This is a blood clot in the lungs and seen as dyspnea,
acute chest pain, cyanosis, tachypnea, and coughing up
blood.
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Review
6. Which of the following diseases is potentially life
threatening and is thought to be transmitted by
close person to person contact?
A. SARS
B. Croup
C. Diphtheria
D. Epiglottitis
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Review
Answer: A
Rationale: Severe Acute Respiratory Syndrome
(SARS) is a viral infection that starts with flu-like
symptoms, which can progress to pneumonia,
respiratory failure, and sometimes death. It is
thought to be transmitted via close person to
person contact.
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Review
6. Which of the following diseases is potentially life threatening
and is thought to be transmitted by close person to person
contact?
A. SARS
Rationale: Correct answer
B. Croup
Rationale: Croup is an inflammatory condition of the larynx and
trachea, marked by a cough, hoarseness, and difficulty in
breathing.
C. Diphtheria
Rationale: Diphtheria is caused by a bacterium that attacks the
membranes of the throat.
D. Epiglottitis
Rationale: Epiglottitis is an acute bacterial infection of the
epiglottis.
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Review
7. A sudden onset of difficulty breathing, sharp chest
pain, and cyanosis that persists despite
supplemental oxygen is MOST consistent with:
A. severe pneumonia.
B. myocardial infarction.
C. a pulmonary embolism.
D. a spontaneous pneumothorax.
73
Review
Answer: C
Rationale: Signs of an acute pulmonary embolism
(PE) include a sudden onset of difficulty breathing,
sharp (pleuritic) chest pain, and cyanosis that
persists despite the administration of high-flow
oxygen. Patients who are immobile for prolonged
periods of time (ie, confined to a hospital bed) are
prone to a PE.
74
Review
7. A sudden onset of difficulty breathing, sharp chest pain, and
cyanosis that persists despite supplemental oxygen is MOST
consistent with:
A. severe pneumonia.
Rationale: This is an acute bacterial or viral infection associated with
a fever, cough, and productive sputum.
B. myocardial infarction.
Rationale: A heart attack is associated with chest pain, sudden onset
of weakness, nausea, sweating, and discomfort.
C. a pulmonary embolism.
Rationale: Correct answer
D. a spontaneous pneumothorax.
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Rationale: This is when air escapes into the pleural cavity.
Review
8. All of the following are causes of acute dyspnea,
EXCEPT:
A. asthma.
B. emphysema.
C. pneumothorax.
D. pulmonary embolism.
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Review
Answer: B
Rationale: Emphysema—a form of chronic obstructive
pulmonary disease (COPD)—is a chronic
respiratory disease; therefore, it presents with
progressively worsening dyspnea. Asthma,
pulmonary embolism, and pneumothorax are all
acute conditions; therefore, they typically present
with an acute onset of dyspnea.
77
Review
8. All of the following are causes of acute dyspnea, EXCEPT:
A. asthma.
Rationale: Asthma is an acute condition with a sudden onset.
B. emphysema.
Rationale: Correct answer
C. pneumothorax.
Rationale: Pneumothorax is an acute condition with a sudden
onset of dyspnea.
D. pulmonary embolism.
Rationale: Pulmonary embolism is an acute condition with a
sudden onset of dyspnea.
78
Review
9. An acute bacterial infection that results in swelling
of the flap that covers the larynx during swallowing
is called:
A. croup.
B. laryngitis.
C. epiglottitis.
D. diphtheria.
79
Review
Answer: C
Rationale: Epiglottitis—a potentially life-threatening
illness—is an acute bacterial infection that causes
swelling of the epiglottis (the flap the covers the
larynx during swallowing). It is characterized by a
sudden onset of high fever, difficulty breathing,
stridor, drooling, and varying degrees of
hypoxemia.
80
Review
9. An acute bacterial infection that results in swelling of the flap that
covers the larynx during swallowing is called:
A. croup.
Rationale: This is an inflammatory condition of the larynx and trachea,
marked by a cough, hoarseness, and difficulty in breathing.
B. laryngitis.
Rationale: This is an inflammation of the larynx, usually accompanied by
hoarseness and coughing.
C. epiglottitis.
Rationale: Correct answer
D. diphtheria.
Rationale: This is caused by a bacterium that attacks the membranes of
the throat.
81
Review
10. Bronchospasm is MOST often associated with:
A. asthma.
B. bronchitis.
C. pneumonia.
D. pneumothorax.
82
Review
Answer: A
Rationale: Asthma—a reactive airway disease—is
caused by bronchospasm (sustained constriction of
the bronchioles). Common triggers to an acute
asthma attack include environmental allergens,
stress, and temperature changes.
83
Review
10. Bronchospasm is MOST often associated with:
A. asthma.
Rationale: Correct answer
B. bronchitis.
Rationale: Bronchitis is the inflammation of the mucous
membrane in the bronchial tubes of the lungs.
C. pneumonia.
Rationale: Pneumonia is an inflammation of one or both lungs.
D. pneumothorax.
Rationale: Pneumothorax is the presence of air or gas in the
pleural cavity surrounding the lungs, causing pain and difficulty
in breathing.
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